• For your own protection, PALS requires that associates carry adequate automobile insurance if you are using your own vehicle for transportation of clients. You should contact your own insurance agent for information and insurance.

• PALS Associates do not administer medications. PALS are permitted to prompt, remind and assist with medication with a signed release from the family.

• If you are hired, you will agree not to work for any client of PALS for a period of one year after the end of your association with PALS.

PARTNERS TO ASSIST IN LIVING SERVICESPO Box 1853417 Main StreetRockland, Maine 04841

info@palsforliving.com(207) 594.5805

Date *

Date

MM

DD

YYYY

Name *

Name

First Name

Last Name

Mailing Address *

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

Home Phone

(###)

###

####

Cell Phone

Cell Phone

(###)

###

####

Email Address *

How did you hear about PALS? *

Please list the hours you are available every day of the week: *

For example: Monday - 9 am - 3pm, Tuesday - 10 am -2 pm, etc.

Please check jobs you are interested in: *

Select all areas of care you'd be willing to assist with. In the below section, check all tasks you'd be willing to perform.

Personal Care

Companion Care

End of Life Care

Driving:

If you are willing to drive, you will be required to provide a driver's license number, car registration number, your auto insurance company and your insurance limits for bodily injury and property damage.

Locally (e.g. errands, appointments, recreational rides.)

Long Distances (e.g. airports, hospitals.)

Shopping:

Grocery

Other (gifts, clothes, etc.)

Household:

Washing

Ironing

Sewing

Preparing Meals

Plant Care

Light Cleaning

Light Hauling

Daily Phone Calls

Cleaning Attics/Basements

Minor Repairs

Organizing:

Prepare for trips

Prepare for moving

Paperwork:

Handle personal correspondence

Experience and Volunteer Work: *

Please list any training or experience you have had working with the elderly. (If you have had PCA or PSS Training, please note that and be prepared to email us a copy of your certificate.)